Provider Demographics
NPI:1790745487
Name:GOODWIN, JEREMY DALTON (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DALTON
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-5210
Mailing Address - Country:US
Mailing Address - Phone:256-547-0433
Mailing Address - Fax:256-547-0460
Practice Address - Street 1:431 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5210
Practice Address - Country:US
Practice Address - Phone:256-547-0433
Practice Address - Fax:256-547-0460
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL24747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I082199OtherMEDICARE PTAN
AL511-69544OtherBLUE CROSS BLUE SHIELD LOCATION ID NUMBER
AL10270G2201OtherMEDICARE GROUP PTAN